Madison County Juvenile Court Probation & Detention Care ...



MADISON COUNTY JUVENILE COURTSOCIAL HISTORY 1TO PARENT: IN ORDER TO UNDERSTAND YOUR CHILD’S NEEDS AND PROVIDE THE APPROPRIATE SERVICES FOR YOUR CHILD WE ASK YOU TO COMPLETE THIS FORM IN ITS ENTIRETY. IF YOU HAVE ANY QUESTIONS FEEL FREE TO ASK ONE OF OUR STAFF MEMBERS.AFTER COMPLETING THIS FORM SAVE IT TO YOUR COMPUTER AND E-MAIL IT TO paul.fontaine@TODAYS DATE: Click here to enter a date.§CHILD’S INFORMATION §CHILD’S FULL NAME:___Click here to enter text. LAST FIRST MIDDLEOTHER NAMES THE CHILD USES (ALIAS, NICKNAME):__ Click here to enter text. D.O.B._____Click here to enter a date. PLACE OF BIRTH___Click here to enter text.HOME TELEPHONE:____Click here to enter text.SOCIAL SECURITY #_____Click here to enter text. DRIVER’S LICENSE#______Click here to enter text. ADDRESS:_____Click here to enter text.CITY:_______Click here to enter text.STATE:_____Click here to enter text.ZIP:_____Click here to enter text.MAILING ADDRESS (IF DIFFERENT FROM ABOVE)____Click here to enter text.CITY:______ Click here to enter text.: STATE:_____ Click here to enter text.ZIP:_________ Click here to enter text.RACE:____ Click here to enter text.SEX:_____ Click here to enter text. HT:______ Click here to enter text.WT:_____ Click here to enter text.EYES:___ Click here to enter text.HAIR:___ Click here to enter text. LIST SCARS & TATTOOS:______ Click here to enter text.DOES CHILD HAVE HEALTH INSURANCE: ? YES ? NO INSURANCE PROVIDER:______ Click here to enter text. POLICY # ______ Click here to enter text.INSURANCE PROVIDER (2ND):______ Click here to enter text. POLICY # ______ Click here to enter text.§ SOCIAL SERVICES §HAVE YOU EVER HAD CONTACT WITH A SOCIAL WORKER OR DEPARTMENT OF HUMAN RESOURCES (DHR) WORKER? ? YES ? NONAME OF THE SOCIAL OR DHR WORKER:______ Click here to enter text. COUNTY:_____Click here to enter text._STATE:_____Click here to enter text. PLEASE CHECK ANY BENEFITS FAMILY RECEIVES: ? AFDC ? FOOD STAMPS ? CHILD SUPPORT ? SSI ? DISABILITY § FAMILY §ARE THE NATURAL PARENTS: ? MARRIED ? SINGLE ? DIVORCED ? SEPARATED ? NEVER MARRIED? UNKNOWN WHO IS THE LEGAL GUARDIAN: ? NATURAL PARENTS? MOTHER/STEPFATHER? FATHER/STEPMOTHER? ADOPTIVE PARENTS ? FOSTER PARENTS ?OTHER_Click here to enter text. IF A PARENT(S) IS DECEASED PLEASE LIST NAME & DATE OF DEATH Click here to enter text. legal guardianlegal guardian (1)__Click here to enter text. LAST FIRST MIDDLE DATE OF BIRTH:_____ Click here to enter text.RELATIONSHIP:______ Click here to enter text.ADDRESS: ___ Click here to enter text. ZIP CODE:___ Click here to enter text.HOME TELEPHONE:__ Click here to enter text. WORK TELEPHONE:_____ Click here to enter text.CELL TELEPHONE:___ Click here to enter text.E-MAIL ADDRESS:___ Click here to enter text.EMPLOYER:___ Click here to enter text.OCCUPATION:___ Click here to enter text.legal guardian (2)__Click here to enter text. LAST FIRST MIDDLE DATE OF BIRTH:_____ Click here to enter text.RELATIONSHIP:______ Click here to enter text.ADDRESS: ___ Click here to enter text. ZIP CODE:___ Click here to enter text.HOME TELEPHONE:__ Click here to enter text. WORK TELEPHONE:_____ Click here to enter text. CELL TELEPHONE:___ Click here to enter text.E-MAIL ADDRESS:___ Click here to enter text.EMPLOYER:___ Click here to enter text.OCCUPATION:___ Click here to enter text.FATHER’S NAME:_____ Click here to enter text. LAST FIRST MIDDLE DATE OF BIRTH:______ Click here to enter text.ADDRESS: ___ Click here to enter text.ZIP CODE:___ Click here to enter text.HOME TELEPHONE:____ Click here to enter text. WORK TELEPHONE:_____ Click here to enter text. CELL TELEPHONE:______ Click here to enter text.OTHER TELEPHONE NUMBER:____ Click here to enter text. E-MAIL ADDRESS:_____ Click here to enter text.EMPLOYER:______ Click here to enter text. OCCUPATION:____ Click here to enter text.MOTHER’S NAME:____ Click here to enter text. LAST FIRST MIDDLE DATE OF BIRTH:_____ Click here to enter text.ADDRESS:___ Click here to enter text.ZIP CODE:____ Click here to enter text.HOME TELEPHONE:____ Click here to enter text. WORK TELEPHONE:____ Click here to enter text. CELL:_____ Click here to enter text.E-MAIL ADDRESS:_____ Click here to enter text._EMPLOYER:_____ Click here to enter text. OCCUPATION:______ Click here to enter text.LIST EVERYONE THAT LIVES IN THE HOME TO INCLUDE THE PARENTS/GUARDIAN:NAME:__ Click here to enter text. RELATIONSHIP:_Click here to enter text. AGE:__Click here to enter text.NAME:_Click here to enter text. RELATIONSHIP:__ AGE:_Click here to enter text.NAME:_Click here to enter text. RELATIONSHIP:__ Click here to enter text.AGE:_Click here to enter text. NAME:_Click here to enter text. RELATIONSHIP: _Click here to enter text.AGE:_Click here to enter text.NAME:_Click here to enter text._ RELATIONSHIP:_ Click here to enter text.AGE:_Click here to enter text. NAME:__ Click here to enter text. RELATIONSHIP:_Click here to enter text. AGE:__Click here to enter text.NAME:_Click here to enter text. RELATIONSHIP:__ AGE:_Click here to enter text.NAME:_Click here to enter text. RELATIONSHIP:__ Click here to enter text.AGE:_Click here to enter text.DO YOU AND YOUR CHILD HAVE TRANSPORTATION? ? YES ? NO IS MEANS OF TRANSPORTATION RELIABLE? ? YES ? NOHAVE YOU, THE PARENT, EVER BEEN A VICTIM OF DOMESTIC VIOLENCE? ? YES ? NO IF YES, PLEASE EXPLAIN BY PROVIDING DATES; IF THERE WAS DHR INVOLVEMENT; IF OFFENDER WAS A FAMILY MEMBER; NAME OF OFFENDER:_____ Click here to enter text.WHAT IS THE MONTHLY INCOME FOR YOUR HOUSEHOLD:_ Click here to enter text.§ education §WHAT SCHOOL IS YOUR CHILD CURRENTLY ENROLLED:Click here to enter text. WHAT GRADE IS CHILD IN:_____ Click here to enter text.IF NOT CURRENTLY ENROLLED WHAT WAS LAST SCHOOL ATTENDED:Click here to enter text.LAST GRADE COMPLETED:_____ Click here to enter text._HAS THE CHILD: ? OFFICIALLY DROPPED OUT ? QUIT SCHOOLIS THEIR ATTENDANCE: ? EXCELLENT ? GOOD ? FAIR ? POOR OVERALL GRADES: ? A’s? B’s ? C’s ? D’s? F’sHAS YOUR CHILD EVER RECEIVED: ? IN SCHOOL SUSPENSION? OUT OF SCHOOL SUSPENSION? EXPULSION EXPLAIN WHAT HAPPENED, ENTER DATES:___ Click here to enter text. DOES YOUR CHILD OR HAS YOUR CHILD EVER ATTENDED SPECIAL EDUCATION OR LEARNING STRATEGIES CLASSES? ? YES ? NO IF YES, PLEASE EXPLAIN:____ Click here to enter text.§ behavior §DOES YOUR CHILD SHOW ANY OF THE FOLLOWING BEHAVIORS: (CHECK ALL THAT APPLY) ? RUNAWAY ? TRUANCY? STEALING? ASSAULTIVE ? INSUBORDINATE? HYPERACTIVE? DISRUPTIVE? DIFFICULTY EATING? SEXUALLY INAPPROPRIATE? MOODSWINGS? DIFFICULTY SLEEPING ARE YOU AFRAID OF YOUR CHILD? ? YES ? NO IF YES, PLEASE EXPLAIN:___ Click here to enter text.DOES CHILD HAVE A JOB? ? YES ? NO PLACE OF EMPLOYMENT:___ Click here to enter text.PHONE #___ Click here to enter text.§ MEDICAL §DOES YOUR CHILD HAVE ANY OF THE FOLLOWING?? DIABETIES TYPE:____ Click here to enter text. ? ASTHMA ? SEIZURES ? HEAD INJURY? NONEDOES YOUR CHILD HAVE ANY OTHER MEDICAL CONDITIONS, DISORDERS OR SEXUALLY TRANSMITTED DISEASES? ? YES ? NOPLEASE LIST:___ Click here to enter text.DOES YOUR CHILD HAVE ANY PHYSICAL LIMITATIONS OR DISABILITY THAT MIGHT REQUIRE SPECIAL ASSISTANCE OR ACCOMODATIONS? ? YES ? NO IF YES, PLEASE EXPLAIN_Click here to enter text.PLEASE LIST ALL ALLERGIES (FOODS, MEDICATIONS, INSECT BITES, POLLEN, MOLD):___ Click here to enter text. §mental health §HAS YOUR CHILD EVER BEEN DIAGNOSED WITH A MENTAL DISORDER OR MENTAL ILLNESS? ? YES ? NOPLEASE LIST:____ Click here to enter text.NAME OF DOCTOR WHO MADE DIAGNOSIS:___ Click here to enter text.WHEN WAS DIAGNOSIS MADE?___ Click here to enter text. HAS CHILD EVER REFUSED TO SEE A MENTAL HEALTH WORKER? ? YES ? NO IF YES, PLEASE EXPLAIN:____ Click here to enter text.IS/DOES YOUR CHILD ASSOCIATE WITH DELINQUENT FRIENDS? ? YES ? NO IS YOUR CHILD SEXUALLY ACTIVE? ? YES ? NO WHAT IS YOUR CHILD’S SEXUAL PREFERENCE?__ Click here to enter text.IS YOUR CHILD A PARENT? ? YES ? NO IF YES, HOW MANY CHILDREN:__ Click here to enter text. AGES:__ Click here to enter text. PLEASE LIST ALL MEDICATIONS YOUR CHILD IS TAKING. BELOW ARE SOME OF THE COMMON DRUGS THAT MAY ASSIST YOU IN REMEMBERING YOUR CHILD’S MEDICATION. IF NONE PLEASE CHECK: ? NO MEDICINE ABILIFY ADDERALLALBUTEROLCELEXACONCERTACYMBALTADEPAKOTEEFFEXOR GEODONKLONOPINLITHIUMNEURONTINPAXIL PROZAC REMERON RISPERDALRITALINSEROQUEL TEGRETOLTRAZADONEWELLBUTRINXANAXZOLOFTZYPREXA BIRTH CONTROL MEDICATIONDOSAGENAME THE DOCTOR WHO PRESCRIBED THE MEDICINEDOCTOR’S TELEPHONE NUMBERWHAT IS THE MEDICATION USED FOR?Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.IS YOUR CHILD NOT TAKING HIS/HER PRESCRIBED MEDICATION(S) FOR ANY REASON? ? YES ? NO IF YES, PLEASE EXPLAIN:____ Click here to enter text.§family history§HAS ANYONE IN YOUR FAMILY EVER BEEN DIAGNOSED WITH A MENTAL DISORDER OR MENTAL ILLNESS? ? YES ? NO IF YES, PLEASE EXPLAIN:__ Click here to enter text.HAS ANYONE IN YOUR FAMILY EVER COMMITTED OR ATTEMPTED SUICIDE? ? YES ? NO IF YES, PLEASE EXPLAIN:___ Click here to enter text.HAS YOUR CHILD EVER BEEN HOSPITALIZED OR PLACED IN A TREATMENT CENTER? (PLEASE CHECK ALL THAT APPLY)? PSYCHOLOGICAL ? DRUG/ALCOHOL ? MEDICAL? NONELIST FACILITY, DATE AND REASON FOR ADMISSION AND HEALTH CARE PROFESSIONAL RESPONSIBLE:_ Click here to enter text.HAS YOUR CHILD EVER BEEN ABUSED (PHYSICALLY, SEXUALLY, MENTALLY) OR NEGLECTED? ? YES ? NOOFFENDERS NAME:_Click here to enter text. RELATIONSHIP_Click here to enter text.DATE OF OFFENSE_Click here to enter a date.PLEASE EXPLAIN ALLEGATION:_Click here to enter text.HAS CHARGES BEEN FILED AGAINST THE OFFENDER? ? YES ? NO§ ALCOHOL/DRUGS§DO YOU SUSPECT THAT YOUR CHILD IS USING DRUGS? ? YES ? NO DO YOU SUSPECT THAT YOUR CHILD IS USING alcohol? ? YES ? NOIF YES, LIST SUBSTANCES SUSPECTED AND IF USING NEEDLES:__ Click here to enter text.HAS YOUR CHILD EVER BEEN DRUG TESTED? ? YES ? NO WERE TEST RESULTS: ? POSITIVE ?NEGATIVEIS THERE A HISTORY OF DRUG OR ALCOHOL ABUSE IN YOUR FAMILY? ? YES ? NO IF YES, PLEASE EXPLAIN:_ Click here to enter text.§ LEGAL §HAS YOUR CHILD EVER BEEN CHARGED WITH A JUVENILE OFFENSE? ? YES ? NO HAS YOUR CHILD EVER BEEN PLACED ON PROBATION? ? YES ? NOLIST CHARGE/S:___ Click here to enter text. PROBATION OFFICER:___ Click here to enter text. COUNTY:___ Click here to enter text. STATE:____ Click here to enter text.HAS YOUR CHILD EVER BEEN CHARGED WITH AN ADULT OFFENSE? ? YES ? NO LIST CHARGE:_ Click here to enter text. DO YOU HAVE ANY WEAPONS SUCH AS GUNS OR OTHER DANGEROUS INSTRUMENTS IN YOUR HOME? ? YES ? NO IF YES, PLEASE EXPLAIN:_ Click here to enter text.IF YOU ANSWERED YES TO QUESTION #3, ARE THE WEAPONS LOCKED OR KEPT IN A SAFE PLACE? ? YES ? NOHOW WOULD YOU RATE YOU CHILD’S OVERALL BEHAVIOR? ? EXCELLENT? GOOD? FAIR? POORLIST YOUR CHILD’S POSITIVE QUALITIES AND STRENGTHS:_ Click here to enter text.DO YOU HAVE A GOOD RELATIONSHIP WITH YOUR CHILD? ? YES ? NO PLEASE EXPLAIN:___ Click here to enter text.HAS ANY PARENT, GUARDIAN OR SIBLING EVER BEEN ON PROBATION OR INCARCERATED? ? YES ? NO LIST NAME, OFFENSE AND DATE:__ Click here to enter text.IS THERE ANYTHING ELSE THAT WOULD BE HELPFUL FOR US TO KNOW ABOUT YOUR CHILD OR YOUR FAMILY? ? YES ? NO IF YES, PLEASE PROVIDE AN EXPLANATION Click here to enter text.Click here to enter text.Click here to enter a date.PARENT/GUARDIAN SIGNATURE / PLEASE TYPE NAME DATE Click here to enter text. Click here to enter a date. STAFF SIGNATURE / TYPE NAME DATENOTES (PARENT OR PROBATION OFFICER): Click here to enter text.SAVE THIS TO YOUR COMPUTER AND E-MAIL IT TO: paul.fontaine@ ................
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